Operative management of postinfarction ventricular septal defect

Postinfarction ventricular septal defect (VSD) remains a surgical challenge because it is technically difficult to reconstruct the septum during the acute phase of a transmural myocardial infarction, and it is a relatively uncommon operative procedure. Conservative treatment is not advisable because most patients develop congestive heart failure and cardiogenic shock, and die. Surgery should be performed soon after the diagnosis in most patients. Hemodynamically compromised patients should have intra-aortic balloon pump, vasodilators, inotropes and, if necessary, assisted ventilation. Coronary angiography should be performed before surgery because approximately two-thirds of the patients have multivessel disease, and concomitant revascularization is important to improve surgical outcome. Classical operative techniques included infarctectomy and reconstruction of the ventricular septum and free walls of the heart with Dacron patches. Since 1987, we have used a novel operative technique, whereby the left ventricle is largely excluded from the infarcted muscle using a bovine pericardial patch sutured to its healthy endocardium. Because right ventricular dysfunction has been identified as an important determinant in the outcome of these patients, we believe that this newer procedure is preferable to previous ones because it leaves the right ventricle undisturbed. From 1980 to 1994, we treated 67 patients with postinfarction VSD using operative techniques that evolved from infarctectomy and reconstruction of the septum with Dacron patches to pericardial patch exclusion of the left ventricle. Thirty-eight patients were in cardiogenic shock when operated on. The overall operative mortality rate was 13.4% and the 10-year actuarial survival rate was 62% +/- 6%. We believe that repair of postinfarction septal rupture by the infarct exclusion technique has improved the outcome of these patients, particularly in those with posterior ventricular septal defect and cardiogenic shock.